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LEISHMANIA Dr.K.S.Kumudha Valli I yr P.G. MD Microbiology Madras Medical college Rajiv Gandhi GGH, Chennai – 3 .


LEISHMANIA Leishmania named after Sir William Leishman. It is a flagellate protozoan . It causes KALA – AZAR, Indian visceral leishmania. Life cycle – 2 hosts. Mammalian host vector-female sand fly (P.argentipes) Amastigote form promastigote form


TERMINOLOGY Amastigote- rounded form with no external flagella Axoneme- axial filament Epimastigote- flagella originates from side of the body to run along as short undulating membrane. Kinetoplast lies anterior to nucleus Promastigote- flagella from anterior end.Kinetoplast lies anterior to nucleus Trypomastigote- flagella arises from posterior end. Kinetoplast lies in posterior end. Undulating membrane- flange of protoplasm formed by the flagellum while curving around the body.


SPECIES – CLASSIFICATION(2TYPES) Leishmania donovani complex L.donovani donovani L.donovani infantum L.donovani chagasi L.donovani archibaldi Leishmania tropica Leishmania major Leishmania aethiopica Leishmania mexicana comp. L.mexicana mexicana L.mexicana amazonensis L.mexicana venezuelensis L.mexicana pifanoi Leishmania braziliensis complex L.braziliensis braziliensis L.braziliensis guyanensis L.braziliensis panamensis L.braziliensis peruviana


LEISHMANIA DONOVANI Sir William Leishman,1900 found parasite in spleen smear in calcutta. From patient died of Dum dum fever or KALA – AZAR. Reported in London in 1903. In 1903,Donovan reported same parasite in Madras from spleen smear. Hence,the name leishmania donovani . Causes: KALA – AZAR or viseral leishmania . PKDL(post kala azar dermal leishmania )


PARASITE EXIST IN 2 FORMS AMASTGOTE- in Man (LD body) Axoneme Vacuole Blepharoplast Kinetoplast Parabasal body Nucleus Found intracellular. PROMASTIGOTE- in Sandfly Flagella Axoneme Vacuole Blepharoblast Parabasal body Nucleus

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LIFE CYCLE IN DEFINITIVE HOSTS: Promastigote Promasigote engulfed by histiocytes Binary fission Amastigote IN INTERMEDIATE HOSTS Amastigote Amastigote in mid-gut promastigote


KALA – AZAR It is visceral leishmaniasis – first characterised in India. Kala azar,black sickness,Dum Dum fever,Burdwan fever or tropical splenomegaly. CLINICAL FEATURES: Transmitted by sandfly P.argentipes. Transmitted by: blood transfusion sexual contact innoculation& congenitally. 3% deveiop typical kala azar syndrome. Incubation period- 2 to 6 months. Cutaneous leison at the site of bite is not seen in Indian patients.

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Onset – insidious. Fever – may be continuous,remittant or irregular. Splenomegaly starts early--- progressive and massive. Hepatomegaly and lymphadenopathy also occur. Emaciation and anaemia occurs. Skin becomes dry,rough,darkly pigmented. Hair becomes thin & brittle. Epistaxis, bleeding gums common. 10 to 20% who recover develop post kala azar dermal leishmaniasis(PKDL). Leisons 3 types: 1.Depigmented macules – trunk & extremitis. 2.Erythematous patches(butterfly patch). 3.Granulomatous nodules.

post kala azar dermal leishmaniasis(PKDL):

post kala azar dermal leishmaniasis(PKDL)


PATHOLOGY Invasion of reticuloendothelial system by L.donovani Parasitised macrophage disseminate infection all parts of body Spleen most commonly affected Grossly enlarged Capsule is thickened due to perisplenitis Soft & friable due to absence of fibrosis

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Liver enlarged- kupffer cells,vascular endothelial cells heavily parasitised.hepatocytes not affected. LFT normal. Fatty degeneration seen – nutmeg appearance. Bone marrow heavily infiltrated. Anaemia: increased destruction – hypersplenism. autoantibodies to RBC.


LABORATORY DIAGNOSIS PARASITIC DIAGNOSIS microscopy culture animal inoculation IMMUNODIAGNOSIS serological tests -CFT, IFA, IHA,ELISA, DAT Non specific serological tests: - Aldehyde test of Napier -Antimony test of Chopra Skin test Montenegro test MOLECULAR DIAGNOSIS - PCR

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Demonstration of parasites in material obtained from patients: MICROSCOPY: 1.PERIPHERAL BLOOD: Amastigote inside circulating monocytes. Thick blood film. 2.BONE MARROW ASPIRATE: Most common diagnostic specimen. Sternum at the level of 2 nd and 3 rd intercostal space. 0.5ml marrow fluid. 3.SPLEEN ASPIRATE: Richer in parasites,valuable for diagnosis. Dangerous bleeding may occur. SMEAR STAINED BY LEISHMAN,GIEMSA OR WRIGHT STAINS, EXAMINED UNDER OIL IMMERSION.

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CULTURE: NNN(novy-Mac neal- Nicolle) medium – rabbit blood agar slopes with lock’s sl with antibiotics. Incubated at 24·C. ANIMAL INOCULATION: Not used routinely. Demonstration of antibodies: SPECIFIC LEISHMANIAL ANTIGENS: Demonstrate specific antigen. CFT, IFA, IHA,ELISA Used. DAT- highly specific and sensitive. NON SPECIFIC NON LEISHMANIAL ANTIGENS: WKK ANTIGEN from human tubercle bacilli is used.

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Non specific serum test: NAPIER’S ALDEHYDE TEST: 1ml of clear serum of patient + drop of formalin shake and kept at room temp Jellification & opacification within 3 – 30min(POSITIVE) CHOPRA’S ANTIMONY TEST: 0.2ml serum diluted 1 in 10ml distilled water, Ovrelayed by 4% urea stibamine thick flocculent disc within 10 – 15min(POSITIVE)

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Absence of hypersensitivity to leishmanial antigen: MONTENEGRO SKIN TEST---- 0.1ml of killed promastigote antigen intradermally read after 72hrs. POSITIVE: dermal leishmania & recovered from kala azar. NEGATIVE: active case of kala azar. Contributory findings in clinical laboratory tests: Normocytic normochromic anaemia Neutropenia , leucopenia& thrombocytopenia. Serum globulin elevated,reversal of albumin-globulin ratio.




TREATMENT Pentavalent antimonal sodium stibogluconate—IV 600mg daily for 6 days. Pentamidine 4mg/kg/day given IM for 10days. Aminoglycoside antibiotics (paromomycin) 14mg/kg bd wt IM or IV 3 – 4 weeks. Amphotericin 0.25 to 1mg/kg/day for 8 weeks. PREVENTION: Eradication of sandfly. Personal prophylaxis by using anti-sandfly measures.

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Leishmania causing cutaneous leisons Old World New World cutaneous Leishmania cutaneous Leishmania L.Major L.braziliensis L.Tropica L.mexicana L.aethiopica


CLINICAL FEATURE & EPIDEMIOLOGY OLD WORLD CUTANEOUS LEISHMANIA: THE ANTHROPONTIC URBAN TYPE: Painless dry ulcerating leison disfiguring scar. By L.tropica,mainly in children. Vector is P.sargenti . THE ZOONOTIC RURAL TYPE: Multiple,moist,inflamed ulcers. By l.major . Vector is P.papatasi . THE NON-ULCERATIVE & OFTEN DIFFUSE LEISON: By L.aethiopica . Vector is P.longipes .

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THE ORIENTAL SORE: Small papule raised indurated leison with surrounding erythema Slightly depressed papery scar. Leisons over face and hands. DIAGNOSIS: microscopic demonstration of amastigote form from edges of leison . Culture – NNN Medium. Intradermal test – MONTENEGRO REACTION – Positive.

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CELL MEDIATED IMMUNITY GOOD LACKING Heal spontaneosly DIFFUSE CUT. DOC- pentavalent antimonials LEISON Others:metronidazole,rifampicin , Local application of heat. Numerous, nodular non- ulcerating leison over face & limbs.

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LEISHMANIASIS RECIDIVANS: Chronic leisons with alternating periods of activity & healing. Characterised by central scar with peripheral activity. Seen in persons with high degree of cell medited immunity. Lesions similar to tuberculoid leprosy or lupus. Treatment - Local application of heat. ESPUNDIA or MUCOCUTANEOUS LEISHMANIA: Late consequence of cutaneous leishmania. By L.braziliensis. Granuloma at mucocutaneous junctions in face Gross destruction of soft tissue & cartilage Marked disfigurement Secondarily infected by anaerobic bacteria.

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